MEDICAL SECURITY INDEX

Healthcare systems may face increasing structural pressure when several forms of vulnerability occur at the same time. HSSF Version 1.0 examines six dimensions:

The framework does not assume that any one indicator can explain healthcare-system stress on its own. Instead, it identifies countries where several measurable stressors coexist.

A High or Extreme classification does not mean that a healthcare system has collapsed. A Low classification does not mean that a country is free from healthcare, humanitarian, or security challenges.

HSSF is intended to support:

• Comparative research
• Public-health and humanitarian analysis
• Policy discussion
• Journalism and public communication
• The identification of countries that may warrant closer study

The Version 1.0 MSI dataset includes 50 countries selected through purposive sampling based on:

• Relevance to conflict-related healthcare-system stress
• The presence of conflict, displacement, healthcare-capacity, or demographic pressures
• The availability of core indicators

The sample is intended for exploratory comparative analysis. It is not representative of every country globally and should not be interpreted as a complete global ranking. Future versions may adopt a more systematic country-inclusion rule as MSI expands its coverage and strengthens its data-completeness requirements.

The HSSF calculation follows four steps.

Indicator-specific normalization

HSSF does not use statistical standardization.

• Instead, MSI uses indicator-specific conversions when necessary
• Conflict fatalities are expressed per 100,000 people
• Conflict-related displacement is expressed per 100,000 people
• Population under age 15 is expressed as a percentage
• Skilled birth attendance is expressed as a percentage
• Hospital-bed density is already expressed as a population-adjusted rate

After these conversions, indicators are evaluated against fixed thresholds. The term normalization refers to per-capita or percentage conversion, not statistical normalization.

No imputation

MSI does not:

• Replace missing values with zero
• Statistically estimate missing observations
• Assume that unavailable data indicate the absence of stress

Only genuine zero values reported by the source dataset are recorded as zero.

Equal weighting and calculation:

Each indicator contributes one point. No indicator receives additional weight.

The total HSSF score is:

The minimum possible score is 0. The maximum possible score is 6.

Equal weighting was selected to:

Equal weighting does not imply that the six indicators have equal real-world or causal importance.

HSSF classifications:

Underlying HSSF score	Classification
0–1	Low
2–3	Moderate
4–5	High
6	Extreme

The classification scale is ordinal: Low → Moderate → High → Extreme

Display Coding

Some figures and maps may encode the four classifications numerically:

Display code	Classification
1	Low
2	Moderate
3	High
4	Extreme

The 1–4 display code is used only for visualization. It is not the underlying HSSF score, which ranges from 0 to 6.

Version 1.0

HSSF Version 1.0 was developed before MSI adopted a formal complete-data eligibility policy. Some Version 1.0 classifications were retained despite missing values in the primary dataset. These classifications should be interpreted as provisional and will be reassessed in a future methodological release.

Future releases

Beginning with the next HSSF version: A country must have values for all six component indicators to receive a classification.

Countries with one or more unresolved missing indicators will be labeled: Insufficient Data

Insufficient Data does not indicate low healthcare-system stress or low humanitarian need. It means that MSI cannot calculate the HSSF consistently using all six required indicators.

When a primary standardized dataset does not provide a required observation, MSI may consider an approved alternate source.

Potential alternate sources include:

1. Official national health ministries
2. National statistical authorities
3. United Nations agencies
4. Other intergovernmental organizations
5. Peer-reviewed research
6. Recognized humanitarian or healthcare research organizations

An alternate value may only be used when:

• it measures the same indicator
• its unit is compatible with the HSSF definition
• the reference year is documented
• the geographic coverage is appropriate
• the methodology or source record is publicly accessible
• and the substitution undergoes internal review before publication

Data status	Meaning
Standardised	All six indicators use MSI’s primary datasets
Supplemented	At least one indicator uses an approved alternate source
Insufficient Data	One or more required indicators remain unavailable

Countries using alternate-source data should be identified in MSI’s technical records.

Alternate values may differ from primary standardized datasets in:

HSSF is intended to help answer: Where do multiple measurable structural pressures coexist?

It is not intended to answer:

• Which country has the best or worst healthcare system?
• Whether a healthcare system will collapse
• Whether a country is safe
• Whether one indicator causes another
• Whether a government is responsible for observed conditions
• How healthcare stress is distributed within every region of a country

HSSF classifications should be interpreted alongside:

HSSF Version 1.0 has several important limitations.